EX-99.5(IV) 3 b43817agexv99w5xivy.txt FORM OF APPLICATION . . .
[NEW ENGLAND FINANCIAL LOGO] Exhibit (5)(iv) P.O. BOX 642 BOSTON, MA 02116-0642 APPLICATION TO NEW ENGLAND LIFE INSURANCE COMPANY For Company Use Only (NELICO), BOSTON, MASSACHUSETTS FOR A VARIABLE ANNUITY No.__________________ ==================================================================================================================================== 1. ANNUITANT _________________________________________________ Social Security No. [ ][ ][ ] [ ][ ] [ ][ ][ ][ ] Name (Print as it should appear in contract) Date of Birth [ ][ ] [ ][ ] [ ][ ] _________________________________________________ month day year Street Address _________________________________________________ Sex [ ] Male [ ] Female City State Zip ==================================================================================================================================== 2. OWNER [ ] INDIVIDUAL [ ] TRUST/CORPORATION [ ] JOINT OWNERS (If different from annuitant) (please complete the Trustee Certification) A. B. (Co-Owner) _________________________________________________________________ ______________________________________________________________ First Middle Last First Middle Last _________________________________________________________________ ______________________________________________________________ Street Address Street Address _________________________________________________________________ ______________________________________________________________ City State Zip City State Zip Social Security/T.I.N. [ ][ ][ ] [ ][ ] [ ][ ][ ][ ] Social Security/T.I.N. [ ][ ][ ] [ ][ ] [ ][ ][ ][ ] Date of Birth/ [ ][ ] [ ][ ] [ ][ ] Sex [ ] Male Date of Birth [ ][ ] [ ][ ] [ ][ ] Sex [ ] Male Date of Trust month day year [ ] Female month day year [ ] Female ==================================================================================================================================== 3. BENEFICIARY (For a Trust, Trustee is Beneficiary) 4. CONTINGENT ANNUITANT PRIMARY Spouse of [ ] 2a [ ] 2b [ ]NA If jointly owned and neither Owner is the Annuitant, indicate which Owner is to be the Contingent Annuitant. [ ] 2a [ ] 2b _____________________________ [ ][ ][ ] [ ][ ] [ ][ ][ ][ ] Name Social Security _____________________________ [ ][ ][ ] [ ][ ] [ ][ ][ ][ ] If individually owned and the Owner and Annuitant are Name Social Security different, the Owner is the Contingent Annuitant. SECONDARY Spouse of [ ] 2a [ ] 2b [ ] NA _____________________________ [ ][ ][ ] [ ][ ] [ ][ ][ ][ ] Name Social Security ==================================================================================================================================== 5. TYPE OF CONTRACT [ ] IRA [ ] Roth IRA [ ] SEP IRA [ ] 457/Deferred Compensation [ ] IRA Rollover [ ] SIMPLE IRA [ ] TSA (403b) [ ] Qualified Plan (type_________________) [ ] Non-Qualified [ ] Other______________________________________ ==================================================================================================================================== 6. PURCHASE PAYMENT(S) b) Automatic Payment Plan Please withdraw $____________________________ Initial Payment of $_________ or Transfer Amount of $__________ Apply toward tax year ____________ If new, please complete MSA or ACH a) Bill $ ______________________________ application from prospectus. Otherwise, indicate MSA or ACH number. [ ] Monthly [ ] Quarterly [ ] Semi-Annually [ ] Annually ____________________________________________ ==================================================================================================================================== 7. BILLING If established, please indicate Group ID Number [ ][ ][ ][ ][ ][ ][ ][ ][ ] Billing Address ________________________________________________________________________________ ==================================================================================================================================== ALL PURCHASE PAYMENTS MUST BE MADE PAYABLE TO NEW ENGLAND FINANCIAL. DO NOT MAKE CHECKS PAYABLE TO THE REGISTERED REPRESENTATIVE OR LEAVE THE PAYEE BLANK.
NEV APP-31 (02/2000) AGS C-1 ==================================================================================================================================== 8. ADDITIONAL INFORMATION ADMINISTRATIVE OFFICE USE _________________________________________________________________ Additions and Amendments _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________
================================================================================ 9. MATURITY Maturity Date will be age 90 if the contract is issued in NY. Otherwise, the Maturity Date will be age 95. The age at Maturity is based on the oldest of the Owner(s) and the Annuitant. ================================================================================ 10. SIGNATURES NOTICE TO APPLICANT: FOR FLORIDA RESIDENTS ONLY: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. FOR NEW JERSEY RESIDENTS ONLY: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. FOR ARKANSAS, KENTUCKY, MAINE, LOUISIANA, NEW MEXICO, OHIO, PENNSYLVANIA, AND WASHINGTON, D.C. RESIDENTS ONLY: Any person who knowingly and with intent to defraud any insurance company or other person files an application or submits a claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and subjects such person to criminal and civil penalties. ANNUITY PAYMENTS OR SURRENDER VALUES, WHEN BASED UPON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND NOT GUARANTEED AS TO A FIXED DOLLAR AMOUNT. Responses Completed by Owner A. [ ] Yes [ ] No WILL THE ANNUITY APPLIED FOR REPLACE ONE OR MORE EXISTING ANNUITY OR LIFE INSURANCE CONTRACTS? (If yes, explain in section 8) B. [ ] Yes [ ] No DOES THE OWNER OR APPLICANT(S) HAVE ANY EXISTING ANNUITIES OR INSURANCE? C. [ ] Yes [ ] No DO YOU BELIEVE THAT THIS CONTRACT WILL MEET YOUR FINANCIAL OBJECTIVES? GENERAL. To the best of my knowledge and belief, the answers recorded are true and complete. My agreement in writing is required to any change made by the Company as to information in the Application. WHEN THE CONTRACT TAKES EFFECT. The contract will take effect as of the latest of: (a) the date of the Application; (b) the date the first purchase payment and first premium for any riders are paid; and (c) any date of issue that is requested; provided that this Application can be approved by the Company as submitted. Owner's Social Security or Employer Identification Number: _____________________ [ ] I AM [ ] I AM NOT subject to backup withholding under Section 3406(a)(1)(C) of the Internal Revenue Code. Under penalties of perjury, I certify that the information provided in this section is true, correct, and complete. Signed at __________________________________________ On ______________________ __________________________________________________ City, State (month/day/year) Owner Signature __________________________________________________ Joint Owner Signature
Responses completed by Registered Representative D. [ ] Yes [ ] No DO YOU HAVE REASON TO BELIEVE THAT REPLACEMENT OR CHANGE OF ANY EXISTING INSURANCE OR ANNUITY MAY BE INVOLVED? E. [ ] Yes [ ] No DOES OWNER (ANNUITANT IF NON-NATURAL PERSON) APPEAR TO BE IN GOOD HEALTH AND MENTALLY COMPETENT? (IF NO, GIVE DETAILS IN SEPARATE MEMO) ___________________________________________________ __________________________________ ___________________________________________ Registered Representative Signature Printed State License Identification Number Accepted by the Company at the Administrative Office by ________________________________ Date _________________________________ Principal Signature (month/day/year)
NEV APP-31 (02/2000) AGS C-2